State of Kuwait
Ministry of Health
Kuwait and Food and Drug Control

دولة الكويت
وزارة الصحة
ادارة الرقابة الدوائية و الغذائية
KDFC: ADR Reporting Form

Patient information

Here goes some personal information about your patient, all these information will be kept secret and used only for statistical information.
Patient name or initals
Age: *
in years
Gender *
 male 
 female 
Weight *
in Kilograms (Kgs. )
Hight *
in Centimeters (CMs)

Reporter information

Here goes your information as a reporter so we can contact you if we need further information.
Name or initials of the reporter *
Doctor or pharmacist or nurse .. etc
Email *
Phone Number
Optional
Can we contact you? *
 Yes, By E.mail 
 Yes, By Phone 
 Yes, By E.mail OR Phone 

Issue details

here we need all the information related to the ADR,Side effects , harmful effect which you exprinced
Suspected product BRAND name: *
Write the name of the product which you suspect it's the Reason for what you've experinced
Suspected product Chemical name: *
The name will be mentioned on the pack as an active ingredient
Reason for taking the drug: *
Dose/Route/Frequency of taking the drug: *
example: 500 mg/ Oral / twice daily
What was the problem the patient experienced after using the product? *
Was the problem solved when you stopped using the product? *
 Yes 
 No 
 I'm still using the product 
 I don't know 
Did the problem Re appear after introduction of the suspected drug again? *
 Yes 
 No 
 Didn't re use the product 
 I don't know 

Detailed information:

These information are optional but needed to help us to perform a full assessment
Specific antagonist used :
if available
Other drugs taken on the same time:
Pre- existing medical history :
Hepatic , cardiac , pregnancy , renal , .. etc
More information
Please provide any more information or comments you wish us to know
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